Discusses common Achilles tendon problems. Covers tendinopathy, which includes tendinitis and tendinosis. Also covers tendon tear or rupture, paratenonitis, peritendinitis, and bursitis. Discusses symptoms such as pain and swelling in back of leg or heel.

Achilles Tendon Problems

Topic Overview

What is the Achilles tendon?

The
Achilles tendon connects the calf muscle to the heel bone. It lets you rise up on
your toes and push off when you walk or run.

What are common Achilles tendon problems?

The
two main problems are:

Achilles tendinopathy. This includes one of two conditions:

Tendinitis. This actually means "inflammation of the tendon." But inflammation is
rarely the cause of tendon pain.

Tendinosis. This refers to tiny
tears (microtears) in the tissue in and around the tendon. These tears are caused by overuse. In
most cases, Achilles tendon pain is the result of tendinosis, not tendinitis.
Some experts now use the term tendinopathy to include both inflammation and
microtears. But many doctors may still use the term tendinitis to describe a
tendon injury.

Achilles tendon tear or rupture. An Achilles tendon also can partially tear or
completely tear (rupture). A partial tear may cause mild or no symptoms. But a
complete rupture causes pain and sudden loss of strength and movement.

Problems with the Achilles tendon may seem to happen
suddenly. But usually they are the result of many tiny tears in the tendon that
have happened over time.

Achilles tendinopathy is likely to occur in men older than 30. Most Achilles tendon ruptures occur in people 30 to 50 years old who are recreational athletes ("weekend warriors"). Ruptures can also happen in older adults.

What causes Achilles tendon problems?

Achilles tendinopathy is most often caused by overuse or repeated movements during sports, work, or other activities. For example, if
you do a lot of pushing off or stop-and-go motions when you play sports, you
can get microtears in the tendon.

Achilles tendon rupture is most often caused by a sudden, forceful motion that stresses the calf muscle. This
can happen during an intense athletic activity or even during simple running or
jumping. Middle-aged adults are especially likely to get this kind of
injury.

What are the symptoms?

Symptoms of Achilles tendinopathy include swelling in the ankle area and mild or severe pain. The pain
may come on gradually or may only occur when you walk or run. You may have less
strength and range of movement in the ankle.

Symptoms of an Achilles tendon rupture may include a sudden, sharp pain. Most people feel or hear a pop
at the same time. Swelling and bruising may occur. You may not be able to
point your foot down or stand on your toes.

How are Achilles tendon problems diagnosed?

Your
doctor can tell if you have an Achilles tendon problem by asking questions
about your past health and checking the back of your leg for pain and swelling.

If your symptoms are
severe or don't improve with treatment, your doctor may want you to get an
X-ray,
ultrasound scan, or
MRI.

How are they treated?

Treatment for mild Achilles
tendon problems includes rest,
over-the-counter pain medicine, and stretching
exercises. You may need to wear well-cushioned shoes and change the way you
play sports so that you reduce stress on the tendon. Early treatment works best
and can prevent more injury. Orthotic shoe devices can also help reduce stress on the tendon.

Even in mild cases, it can take weeks
to months of rest for the tendon to repair itself. It's important to be patient
and not return too soon to sports and activities that stress the tendon.

Treatment for severe problems, such as a torn or ruptured tendon, may
include surgery or a cast, splint, brace, walking boot, or other device that
keeps the lower leg from moving. Exercise, either in physical therapy or in a
rehab program, can help the lower leg get strong and flexible again. The tendon
will take weeks to months to heal.

Although treatment for Achilles
tendon problems takes time, it usually works. Most people can return to sports
and other activities.

Cause

Achilles tendinopathy is most often caused by:

Overuse or repeated movements during sports,
work, or other activities. In sports, a change in how long, intensely, or often
you exercise can cause microtears in
the tendon. These tears are unable to heal quickly and will eventually cause pain.
A change in your environment, such as going from a flat
surface to a hill or from a dirt road to a paved road, can also cause these tears.

Injury from repeated push-offs or a stop-and-go motion. These injuries are common in
such activities as running, basketball, tennis, or ballet dancing.

Achilles tendon rupture is most often caused
by:

Sudden, forceful motion that stresses the calf
muscle. This can happen during an intense athletic activity or even during simple
running or jumping, especially in middle-aged adults. A
rupture most often occurs in sports such as
basketball, racquet sports (including tennis), soccer, and softball.

Overstretching the tendon during any activity
when the tendon is already damaged because of Achilles tendinopathy or another
condition.

Symptoms

Symptoms of
Achilles tendinopathy may include:

Pain in the back of the heel, in the
Achilles tendon area. Pain may be mild or severe. Swelling may
occur.

Tenderness in the Achilles tendon area. Tenderness may be
more noticeable in the morning.

Stiffness that goes away as the
tendon warms up with use.

Decreased strength and movement, or a
feeling of sluggishness in the leg.

Symptoms of an
Achilles tendon rupture may include:

A sudden, sharp pain that feels like a direct
hit to the Achilles tendon. There may be a pop when the rupture occurs. This
may be followed by swelling and bruising.

Heel pain. (It may be
severe.)

Not being able to go on tiptoe with the hurt leg.

If you have a partial rupture (tear) of the Achilles
tendon, you may have near-normal strength and less pain after the initial
injury, compared to what you would have after a complete
rupture.

What Happens

Achilles tendinopathy

Achilles tendinopathy starts with repeated small tears in the tendon. These tears may cause no
obvious symptoms. Or they may cause mild to severe pain during movement. As the tearing
continues, the leg may weaken and the tendon pain may become constant. Abnormal
growths (nodules) may form in the tendon, and it may thicken.

Without rest and treatment of Achilles tendinopathy,
you may develop long-lasting (chronic) pain.

Achilles tendon tear or rupture

An Achilles tendon
can partially tear or
completely tear (rupture). A tear usually occurs in the tendon about
1.5 in. (3.8 cm) to
2.5 in. (6.4 cm) above where it attaches to the heel bone. Some doctors believe that this area
is most likely to tear or rupture because of a limited blood supply.

If you don't treat an Achilles rupture, you will feel
weakness in your first steps when you walk. It may feel like walking in the sand. Over time, walking will become difficult.

Other Achilles tendon problems

Other conditions
can affect the Achilles tendon area. These other
conditions are caused by inflammation. They include:

What Increases Your Risk

Sports and physical activity. Overuse and
repeated movements can cause injury and weaken the Achilles tendon. Playing
sports increases the risk of an injury. Activities at work
(such as in construction) and at home (such as gardening) may also increase
your risk.

Sports training errors. Not warming up before running or other activities or suddenly changing your training program
can increase your risk for injury. Increasing your distance, running uphill
more often, or changing your ground surfaces too quickly can increase your risk. Decreased flexibility may also increase the risk of tendon problems.

Age. As you age, the blood supply to the Achilles
tendon area decreases. Most cases of Achilles tendinopathy or rupture occur in
people older than 30.

Weight. If you are very heavy, you have a greater
risk.

Being male. Men are more likely than women to have
an Achilles tendon injury.

Footwear. You may increase your risk if you wear shoes that are worn out, that do not support your feet, or that do not cushion your heel.

Corticosteroid injections in the
Achilles tendon. They can weaken the tendon.

Long-term use of quinolone antibiotics.1 Quinolones include
ciprofloxacin and ofloxacin.

Having
osteoarthritis,
gout, or
rheumatoid arthritis.

When To Call a Doctor

Call your doctor right away if you think you have an
Achilles tendon problem (at or above the back of your ankle) and:

The back of your heel and ankle are very
painful.

You felt a sharp pain like a direct hit to the Achilles
tendon.

You heard a pop in your Achilles tendon when you were
injured.

You aren't able to walk comfortably.

Your
Achilles tendon area has begun to swell.

You have signs of damage
to the nerves or blood vessels. Signs include numbness, tingling, a pins-and-needles
feeling in your foot, and pale or bluish skin.

If you have had an Achilles tendon injury in the past and
you have reinjured your Achilles tendon, call your doctor to find
out what you need to do. Rest your lower leg and foot until treatment
begins.

Watchful waiting

Watchful waiting is a period of time during
which you and your doctor observe your symptoms or condition
without using medical treatment. Watchful waiting is not a good idea if you
have severe pain in the Achilles tendon area. If you think you have injured
your Achilles tendon, call your doctor. Early treatment is most
effective.

If you think you have
Achilles tendinopathy and you have mild symptoms, rest your lower leg and foot
for a couple of days. Follow the other steps in Home Treatment. If you have weakness, cramping, or
constant pain in your Achilles tendon, call your doctor.

Who to see

Health professionals who can diagnosis and treat an
Achilles tendon problem include:

Exams and Tests

Most doctors
diagnose an Achilles tendon problem through a
medical history and physical exam. This includes checking for tenderness, watching how you walk and stand, and comparing the range of motion of your two legs.

Other tests may be done to clarify a diagnosis or to
prepare for surgery. These tests include:

Ultrasound. It may be used to
check whether there is a rupture of the tendon or signs of
tendinopathy.

Treatment Overview

Early treatment usually results in better healing.

Achilles tendinopathy

To treat
Achilles tendinopathy:

Use home treatment. This includes resting your lower leg and foot, stretching the area, wearing cushioned shoes or other orthotics, and switching sports or modifying how you do sports that may have caused the problem.

Follow any
physical therapy that your doctor has
prescribed. This may include stretching and strengthening exercises, deep massage, heat, or
ultrasound.

If your Achilles tendon shortens and
stiffens while you sleep, your doctor may suggest that you wear a
night brace to keep your foot flexed.

If you keep having pain or
stiffness in the ankle area, your doctor may prescribe a walking
boot or other device for 4 to 6 weeks. This keeps your lower leg and foot from
moving. It allows the tendon to heal.

If you still have Achilles
tendon pain after more than 6 months of consistent treatment and rest, you
might need to consider surgery.

Achilles tendon rupture

Immobilizing your leg, followed by
rehab. This prevents movement of the lower
leg and ankle. It allows the ends of the Achilles tendon to reattach and heal.

What to think about

Don't smoke or use other tobacco
products. Smoking slows healing, because it decreases blood supply and delays
tissue repair.

If you have an Achilles tendon rupture, your
decision about whether to have surgery will depend in part on your:

Age and activity level. For example, if you are an older adult who doesn't do
activities that may cause another rupture and who doesn't want the added
risk of surgery, you may choose to use a cast or similar
device.

Medical condition. If you have another medical
condition—such as
diabetes or heart or lung disease—that raises the
risks associated with surgery, you may choose to use a cast or similar
device.

Time since injury. Over time, the torn ends of the tendon shorten and pull away from each other. If they are too far apart, the surgery is less likely to work. If surgery is chosen, many surgeons will wait a few days for the swelling to go down, then do the surgery as soon as possible. Surgery is usually done within 4 to 6 weeks.

Prevention

Most Achilles tendon injuries occur during
sports and can be prevented. If you had an Achilles tendon problem in the past,
it is especially important to try to prevent another injury. To help prevent injury, try to:

Warm up and stretch. Before any sport or
intense activity, gradually warm up your body by doing 5 to 10 minutes of
walking or biking, and then do stretching exercises.
Calf and plantar fascia stretches will stretch the Achilles tendon area. More
general stretches target other muscles, such as the hamstrings and
groin.

Cool down and do more stretching. After intense
activity, gradually cool down with about 5 minutes of easy jogging, walking, or
biking, and 5 minutes of stretches.

Avoid any sport or intense
activity that you are not in condition to do.

Wear shoes that
cushion your heel during sports or any strenuous activity.

Wear
heel pads or other
orthotics that are designed to reduce stress on the
Achilles tendon.

Home Treatment

Home treatment is often used for
Achilles tendinopathy and in
physical therapy or rehabilitation (rehab) after an Achilles
tendon
rupture.

Achilles tendinopathy

Follow these steps to rest,
heal, and strengthen your Achilles tendon and prevent further injury:

Rest your Achilles tendon. Avoid all
activities that strain the tendon, such as stair climbing or running. Try
other activities, such as swimming, while
you give your tendon the days, weeks, or months it needs to heal. Your doctor will tell you what you can and cannot do.

Don't smoke or use other tobacco products.
Smoking slows healing, because it decreases blood supply and delays tissue
repair.

Wear footwear that protects the tendon while it heals.

Quality athletic shoes that support your
arches and cushion your heels can make a big difference in your comfort
and healing. If needed, talk to your physical therapist or
podiatrist about heel pads or
orthotics.

A bandage that keeps your foot
flexed can restrict the motion of the Achilles tendon.

A silicone
sleeve or pad can distribute pressure on the Achilles tendon.

If your Achilles tendon shortens and
stiffens while you sleep, your doctor may suggest that you wear a
night brace to keep your foot flexed.

Achilles tendon rupture

No matter how you treat an Achilles tendon rupture, after treatment it's important to follow your
rehab program. This program helps your tendon heal and
prevents further injury.

Medications

You can use medicine to relieve pain from
Achilles tendinopathy or an
Achilles tendon rupture. The medicine may be prescription or
nonprescription. Be safe with medicines. Read and follow all instructions on the label.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are also often used to treat pain. But most tendon problems don't
involve inflammation, so NSAIDs usually aren't needed. These drugs include
ibuprofen (such as Advil and Motrin) and naproxen (such as Aleve).

Corticosteroid
injections, which sometimes are injected around tendons or into joints to
reduce pain and
inflammation, aren't used to treat Achilles
tendinopathy. They may increase the risk of a tendon rupture.

Surgery

Achilles tendinopathy

Surgery usually isn't
needed to treat
Achilles tendinopathy. But in rare cases, someone
might consider surgery when rubbing between the tendon and the tissue covering
the tendon (tendon sheath) causes the sheath to become thick and fibrous.
Surgery can be done to remove the fibrous tissue and repair any small tendon
tears. This may also help prevent an Achilles tendon
rupture.

Achilles tendon rupture

Surgery is often used to
reattach the ends of a ruptured Achilles tendon. It may provide a better chance of
preventing the tendon from rupturing again compared to using a cast or other device that will keep your lower leg from moving
(immobilization).2

Surgery works best when you
have surgery soon after your injury. Recovering from surgery may take
months. Most surgeons will wait a few days for swelling to go down, then do the surgery as soon as possible. Surgery is usually done within 4 to 6 weeks. You will also need a
rehabilitation (rehab) program to help heal and strengthen the
tendon.

Surgery choices

Surgery for an Achilles tendon rupture
can be done with a single large incision, which is called open surgery. Or it can be done with several small incisions. This is called percutaneous surgery.

What to think about

The differences in age and
activity levels of people who get surgery can make it hard to know if Achilles
tendon surgery is effective. The success of your surgery can depend on:

Your
surgeon's experience.

The type of surgery you have.

How damaged the tendon is.

How soon after rupture the surgery is done.

How soon you start your
rehab program after surgery.

How
well you follow your rehab program.

Talk to your surgeon about his or her surgical
experience. Ask about his or her success rate with the technique that would best treat your
condition.

Other Treatment

Other treatments are often used
for
Achilles tendinopathy or
rupture. Before using other treatments, you most
likely will try rest and medicine to reduce pain and swelling.

Achilles tendon rupture

A
cast or similar device can be used to prevent the
lower leg and ankle from moving (immobilization). This type of treatment may take as
long as 6 months to completely heal a tendon. This is usually followed by a
rehabilitation (rehab) program that helps you regain strength
and flexibility in the tendon and leg. The rehab program may include
physical therapy.

If other treatment doesn't reduce your pain, your doctor may recommend using a cast or other device for 4 to 6 weeks. These devices can prevent your lower
leg and foot from moving and allow the tendon to heal. This is then followed
by physical therapy and changes in your activities.

Experimental treatment

Medical researchers continue to study new ways to treat tendon injuries. Talk to your doctor if you are interested in experimental treatments. Some of the treatments being studied include:

Nitric oxide and glyceryl trinitrate, applied topically (to the skin) over the injury.

Platelet-rich plasma (PRP). In this procedure, blood is drawn from the person and spun at high speeds to separate out the blood cells called platelets. Then the platelets are injected back into the body at the injury site.

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